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�� ��•� � 7r111aeProcessedWhen Submitted Properly Completed. 8e surra 7,e�5i T - <br /> FOR OFFICE USE: APPLICATIQ t lication. <br /> (For Non-Transferable, Revoca <br /> ue �/ <br /> ENVIRONMENTAL HEA pip q •q PUMP&WEAL <br /> (COMPLETE IN TRIPLICATE) `9ol <br /> WATER QUALITY <br /> Application is hereby made to the San Joaquin Local Health District fora Permit to construct and/or' s t O <br /> made in compliance with San Joaquin County Ordinance No. 1862 and the rules and re An�� <br /> �� �} 6 UDG"described.This application is <br /> Exact Site Address leo teo ' u" Local Health District. <br /> 1 <br /> Owner's Name 4E'it own _ ` <br /> Address Phone / 9, <br /> Contractor's Name City — -� <br /> Contractor's Address �j v License# � <br /> — � Business Phpne <br /> Is Certificate of Workman's Compensation Insurance on File With HDA Emergency Phone y� <br /> TYPE OF WORK (CHECK): NEW WELL❑ I -- <br /> DEEPEN ❑ Yes No <br /> WELL CHLORINATI N ❑ WELL ABANDONMENT ❑ RECONDITION❑ DESTRUCTION❑ <br /> REPLACEMENT OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> DISTANCE TO NEAREST: Septic Tank <br /> Sewer Lines Pit Privy <br /> Sewage Disposal Field <br /> Cesspool/Seepage Pit <br /> Property Line Private Domestic Well Other <br /> INTENDED USE Public Domestic Well <br /> ❑ TYPE OF WELL <br /> NDUSTRIAL ❑ CABLE TOOL <br /> DOMESTIC/PRIVATEDRILLED Ilia. of Well Excavation 1 <br /> ❑ DOMESTIC/PUBLIC ❑ Dia. of Well Casing <br /> C1 GRAVEL PACK r <br /> ❑ IRRIGATION DRIVEN -' �-^ r - - - — -Gauge of Casing <br /> ❑ CATHODIC PROTECTIONDepth of Grout Seal <br /> El DISPOSAL ❑ ROTARY ` <br /> ❑ OTHER Type of Grout � <br /> ❑ GEOPHYSICAL Other information <br /> PUMP INSTALLATION: n Surface Seal installed By: <br /> Contractor <br /> PUMP REPLACEMENT: Type of Pump <br /> 93"State Work Done_ H.P. <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: <br /> Well biameter <br /> Describe Material and Procedure Approximate Depth r <br /> i hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ~ <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ an 4 <br /> P Y Y person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring orsub-contracting signature certifles the following:'Y certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California," <br /> I V call for a Gro Inspection prio to grouting and a final inspection. <br /> Signed X <br /> Title: f� <br /> (Draw Pio a on Reverseatde) — Date: <br /> PHASE <br /> FOR DEPARTMENT USE ONLY -� <br /> Application Accepted By <br /> i <br /> Additional Comments Date__ �� i <br /> Phase II Grout Inspection r. <br /> Inspection By Date h III Final Inspection,, } <br /> Inspection 13y Date r <br /> Fee Is Due: ❑ ANNUALLY PER uNir <br /> ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 <br /> ❑ July 1 &ReceivecF By July 31 <br /> BASE EXPLANATION BILLING REMITTANCEREMIT <br /> DATE DATE $ AMOUNT DUE <br /> FEE L],i—P— REMITTED CHECKED <br /> i� AMOUNT <br /> LESS � o� <br /> PRORATJON <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Receivetl 6y Date v <br /> Receipt No. Permit No, <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES ISM <br /> ce Date Mailed Delivered <br /> pl E.HA2ELTON AVE.,P.O.Box 2009 STOCKTON.Ca osIMI <br />